If you’re uninsured, you may have questions about possible penalties for not having coverage. The fine may be bigger than you expect. Here are the details:

Is everyone required to have health insurance or pay a fine?

Most people who can afford to buy health insurance but don’t do so will face a penalty, sometimes called a “shared responsibility payment.” The requirement to have health insurance, which began in 2014, applies to adults and children alike, but there are exceptions for certain groups of people and those who are experiencing financial hardship.

What kind of insurance satisfies the requirement to have coverage?

Most plans that provide comprehensive coverage count as “minimum essential coverage.” That includes job-based insurance and plans purchased on the individual market, either on or off the exchange. Most Medicaid plans and Medicare Part A, which covers hospital benefits, count as well, as do most types of Tricare military coverage and some Veterans Affairs coverage.

Insurance that provides limited benefits generally does not qualify, including standalone vision and dental plans or plans that only pay in the event someone has an accident or gets cancer or another specified illness.

If I don’t have health insurance, how much will I owe?

For 2014, the penalty is the greater of a flat $95 per adult and $47.50 per child under age 18, up to a maximum of $285 per family, or 1 percent of the portion of your family’s modified adjusted gross income that is more than the threshold for filing a tax return. That threshold is $10,150 for an individual, $13,050 for a head of household and $20,300 for a married couple filing jointly.

For 2015, the penalty increases to $325 per adult or 2 percent of income, and in 2016 it will be the greater of $695 or 2.5 percent of income.

The $95 penalty has gotten a lot of press, but many people will be paying substantially more than that. A single person earning more than $19,650 would not qualify for the $95 penalty ($19,650 – $10,150 = $9,500 x 1percent = $95). So the 1 percent penalty is the standard that will apply in most cases, say experts. For example, for a single person whose modified adjusted gross income is $35,000, the penalty would be $249 ($35,000 – $10,150 = $24,850 x 1percent = $249).

The penalty is capped at the national average price for a bronze plan, or about $9,800, according to Brian Haile, the former senior vice president for health policy at Jackson Hewitt Tax Service. The vast majority of taxpayers’ incomes aren’t high enough to be affected by the penalty cap, he says.

Many more people will be able to avoid the penalty altogether because their income is below the filing threshold.

If I owe a penalty for not having insurance in 2014, how do I pay it?

If you had health insurance for only part of 2014 or didn’t have coverage at all, you’ll have to file Form 8965, which allows you to claim an exemption from the requirement to have insurance or calculate your penalty for the months that you weren’t covered.

What if I just realized I face a penalty for 2014. Can I do anything to avoid a penalty next year?

Open enrollment for 2015 coverage ended Feb. 15 but there is a special enrollment period from March 15 to April 30 for uninsured consumers who are just learning of the penalty. That provision applies only to people in the 37 states that use the federal exchange, healthcare.gov, but many of the states running their own health marketplaces have made similar offers.

Are there other circumstances that allow me to get insurance outside the annual open enrollment period?

Yes. If you have a change in your life circumstances such as getting married, adopting a child or losing your job and your health insurance, it may trigger a special enrollment period during which you can sign up for or change coverage and avoid paying a fine. In addition, if your income is low and meets guidelines in the law, you can generally sign up for your state’s CHIP or Medicaid program at any time.

I was uninsured last spring and signed up on the exchange in March 2014 for a plan that started May 1. Will I owe a penalty for the first four months of the year?

No. In October 2013, the Department of Health and Human Services released guidance saying that anyone who signed up for coverage by the end of the open enrollment period on March 31 would not owe a fine for the months prior to the start of coverage.

What if I have a gap in coverage after open enrollment ends? Will I have to pay a fine?

It depends. If the gap in coverage is less than three consecutive months, you can avoid owing a penalty. Subsequent coverage gaps during the year, however, could trigger a fine.

If you have coverage for even one day during a month, it counts as coverage for that month. The penalty, if there is one, would be calculated in monthly increments.

Are parents responsible for paying the penalty if their kids don’t have coverage?

They may be. If you claim a child as a dependent on your tax return, you’ll be on the hook for the penalty if the child doesn’t have insurance. In cases where parents are divorced, the parent who claims the child as a tax dependent would be responsible for the penalty.

Who’s exempt from the requirement to have insurance?

The list of possible exemptions is a long one. You may be eligible for an exemption if:

–Your income is below the federal income tax filing threshold (see above).

–The lowest priced available plan costs more than 8 percent of your income.

–Your income is less than 138 percent of the federal poverty level (about $16,105 for 2015 coverage for an individual) and your state did not expand Medicaid coverage to adults at this income level as permitted under the health law.

–You experienced one of several hardships, including eviction, bankruptcy or domestic violence.

There’s no one-size-fits-all answer. You can claim some of the exemptions when you file your tax return in 2015, but for others, you will have to complete an exemption application available at healthcare.gov.

Are U.S. citizens living overseas subject to the penalty for not having insurance?

If you live abroad for at least 330 days during a 12-month period, you aren’t required to have coverage in the States.

What happens if I don’t pay the penalty?

The IRS may offset your income tax refund to collect the penalty, but that’s about it. Unlike other situations where the tax agency can garnish wages or file liens to collect unpaid taxes, the health law prohibits these activities in cases where people don’t pay the penalty for not having insurance.

This story was originally published March 24, 2014.

]]>http://kaiserhealthnews.org/news/what-are-the-penalties-for-not-getting-insurance/feed/13individual mandate questions 300.jpgkhnwebFAQ: What Are The Penalties For Not Getting Insurance?Health On The Hill: ACA Heads Back To Supreme Courthttp://kaiserhealthnews.org/news/aca-heads-back-to-supreme-court/
http://kaiserhealthnews.org/news/aca-heads-back-to-supreme-court/#commentsTue, 03 Mar 2015 10:00:10 +0000http://kaiserhealthnews.org/?p=524834]]>

Transcript:

MARY AGNES CAREY: Welcome to Health on the Hill, I’m Mary Agnes Carey. The Affordable Care Act is headed back to the Supreme Court. At stake are millions of subsidies that help people in more than three-dozen states afford health care coverage. Julie Rovner, a senior correspondent for Kaiser Health News, joins me now to discuss the case. Hi Julie.

JULIE ROVNER: Hi, Mary Agnes.

MARY AGNES CAREY: What’s this all about? Lay out the case for us.

JULIE ROVNER: Well, it’s certainly not about the constitutionality of the Affordable Care Act. A lot of people are saying that. This is what’s known as a statutory interpretation case, something else that the Supreme Court tends to do when there’s an argument over what Congress meant. Basically, the Supreme Court acts as a referee. And that’s basically what they’re doing here.

JULIE ROVNER: Well, the challengers in this case say the phrase “established by a state” means that only tax credits that are given out in state exchanges are allowed. And that means, as you mentioned, more than three-dozen states that are using the federal exchange, healthcare.gov, can’t provide tax credits to people. Now they say Congress intended to do this in an effort to pressure states to create their own exchanges. Those on the other side, including the government and the people who wrote the law say that’s not the case at all. It was just sort of an odd way that sentence was written and Congress always intended for tax credits to be available to everyone regardless of whether the exchange was established by a state or the federal government. And that’s basically what’s at stake here. We’re looking at a regulation by the Internal Revenue Service that implements that portion of the law that tax credits and the IRS said that everyone should be able to get those tax credits.

MARY AGNES CAREY: Everyone to receive them whether in the state or the federal exchange.

JULIE ROVNER: Well both sides agree on this; and the answer is basically chaos. It would be kind of a mess. Several states actually tried to reform what’s called the non-group market, the individual insurance market, by making insurance available to people with pre-existing conditions but without help for other people to buy insurance or to require them to buy insurance. And it did not work very well. In Kentucky, basically every insurer left the state when they tried it in the 1990s. There are various estimates. Somewhere around 7.5 million people would likely lose their subsidies. Because of the way the law is written, if insurance costs more than 8 percent of your income, you’re not required to buy it. So most of those people would not buy insurance. They wouldn’t have to. The people who would buy insurance are probably the people who need it the most. That would result in a risk pool that is sicker and therefore premiums would have to go up. Estimates are that premiums would go up somewhere in the neighborhood of 35 to 45 percent. Obviously for people who were getting subsidies, their costs would go up enormously. The average subsidy is about $268 and that covers somewhere in the neighborhood of three-quarters of their premium. So they would basically be priced out of these markets. Insurance companies are very worried about this. Hospitals and other health care providers are also worried about this. They’ve all written amicus briefs to the court saying this would be a real disaster if the subsidies were not available in these states where the federal health exchange is being used.

MARY AGNES CAREY: So on Wednesday we’ll have the oral arguments and then the judges begin their deliberations. Take us through some of the issues that guide those deliberations.

JULIE ROVNER: Well as I mentioned this is what’s called a statutory interpretation case. They have to decide whether Congress intended for the subsidies to be available in the state and federal exchanges or just in state exchanges. And mostly when they get these cases, they use what’s called Chevron Deference, that’s a reference to a 1984 case. The way it works is that first it’s a two part test. They look at the language of the law and they say, “Is it straightforward or is it ambiguous?” If they find it ambiguous, then they are suppose to defer to the agency, in this case the IRS, as long as the IRS’ interpretation isn’t unreasonable. That’s why the challengers in this case are trying to make the case that Congress intended for the tax credits to be denied to people using the federal health exchange because that would make the IRS’ interpretation unreasonable, because only if the interpretation is unreasonable, would the Supreme Court then overrule it.

MARY AGNES CAREY: There’s also some issue involved where if the federal government is going to change something with the states, they have to tell the states they’re doing that. That’s one of the issues here.

JULIE ROVNER: That’s right, a number of states in their court filings are saying that when they were deciding whether or not to have a state exchange, they didn’t know, no one ever told them there was a possibility that their residents wouldn’t get these tax credits if they didn’t create an exchange and that’s a violation of other sort of previous court rulings that said you can’t limit things, that you can’t limit what they states get if you don’t tell them what their options are. And frankly as someone who covered this law from its inception, I certainly never heard anybody talk about the idea that only states exchanges would have access to the tax credits. It simply was never discussed.

MARY AGNES CAREY: Thank you so much Julie Rovner, Kaiser Health News.

]]>http://kaiserhealthnews.org/news/aca-heads-back-to-supreme-court/feed/0Supreme Court Meets In Closed Conference To Decide On Hearing Same-Sex Marriage Cases From Several StateskhnmarkbHigh Costs Of HIV Drugs On Some Illinois Insurance Plans May Be Discriminatory, Say Advocateshttp://kaiserhealthnews.org/news/high-costs-of-hiv-drugs-on-some-illinois-insurance-plans-may-be-discriminatory-say-advocates/
http://kaiserhealthnews.org/news/high-costs-of-hiv-drugs-on-some-illinois-insurance-plans-may-be-discriminatory-say-advocates/#commentsFri, 27 Feb 2015 17:25:49 +0000http://kaiserhealthnews.org/?p=524487]]>Two major insurers are charging much more than others for several common HIV and AIDS medications in Illinois, drawing complaints from AIDS advocates that the companies may be trying to discourage high-cost patients from choosing their plans on the federal health insurance marketplace.

Several standard treatments cost more than $1,000 per month on many Coventry Health Care and Humana plans, while some of the same drugs cost as little as $35 on plans other insurers sell on the exchange, according to an AIDS Foundation of Chicago analysis.

“While certainly there are plans on the marketplace that offer good coverage, what we think these companies are doing is putting out a signal that people with HIV are not welcome on these plans,” said John Peller, the foundation’s president and CEO.

The AIDS Foundation warned Coventry, Humana and two other insurers in January letters that the way they are pricing the drugs may violate federal protections against discrimination. The Affordable Care Act forbids insurers from discriminating against people with pre-existing conditions.

This copyrighted story comes from the Chicago Tribune, produced in partnership with KHN. All rights reserved.

Coventry and Humana lowered the costs of some of the drugs in Florida after nonprofits filed a federal complaint there, but prices remain the same in Illinois. Insurers noted that Florida has a state statute that specifically regulates coverage for HIV and AIDS patients, while Illinois does not.

The Illinois insurers said drugs’ rising costs, a changing patient pool and shifting costs of medical services all affect the way they price drugs and design plans.

“Our goals are to help our members be healthy and access the care they need by assisting with the strict patient compliance that these specialty medications require while keeping our health plans affordable,” Coventry spokesman Rohan Hutchings said in an email. All plans on the marketplace include out-of-pocket maximums that limit patients’ annual spending, he added.

Placing drugs for AIDS and HIV, diabetes, cancer and other chronic conditions into higher-cost categories, or tiers, within an insurance plan is sometimes called “adverse tiering” and has been documented by researchers. Patient advocates say the tiering may be a new way for insurers to keep high-cost patients off their plans, a common practice before the Affordable Care Act prohibited it.

A recent Harvard study published in the New England Journal of Medicine found evidence that insurers were adversely tiering HIV and AIDS drugs on 12 of 48 plans sold on the federal exchange in 12 states. People with midrange “silver” plans that were adversely tiered would pay about $3,000 more per year for their drugs than those in other plans, according to the study.

“We can’t say that the intent of these formularies is to discriminate, because we can’t read the minds of the people who made it,” said Dr. Benjamin Sommers, an assistant professor of health policy and economics at the Harvard T.H. Chan School of Public Health and one of the study’s authors. “But the result of these formularies is to discriminate.”

When Washington, D.C.-based Avalere Health looked at drug costs on silver plans in eight states, the consultant found more than a quarter of plans placed five classes of drugs — for HIV and AIDS, cancer and multiple sclerosis — in high-priced specialty tiers.

The AIDS Foundation of Chicago looked at how insurers tiered seven standard treatment regimens recommended by the Department of Health and Human Services. The foundation found that Coventry and Humana place nearly all of the drugs in the treatments in the fifth tier, their highest. Other insurers place some of the same drugs in lower tiers, resulting in lower treatment costs.

Because insurers don’t make public the discounts they negotiate with pharmaceutical companies, the foundation estimated costs based on average wholesale prices, which it says range from about $2,400 per month to about $3,300 for the seven treatments. Patients are required to pay half the cost of tier-five drugs on most Coventry and Humana plans, according to the analysis.

Nancy Daas, a partner at Chicago-based health industry consultant CMC Advisory Group, said the pricing of HIV and AIDS treatments is not the result of discrimination but a reflection of the costs insurers pay for the drugs.

“I’m not saying it’s easy for people (to afford them), but these drugs cost a lot of money,” Daas said.

A year’s worth of a common, single-pill regimen called Atripla costs $26,000 to buy wholesale, up from $14,000 a year when the pill was introduced in 2006, Humana spokeswoman Cathryn Donaldson said in an email.

“Humana is committed to working with pharmaceutical manufacturers and organizations representing individuals with HIV/AIDS and similar organizations for people with complex chronic conditions to develop longer-term strategies addressing these underlying concerns of pharmaceutical access and affordability,” Donaldson said.

Daas also noted that drug pricing affects the costs of other plan benefits, and vice versa. By charging more for certain drugs, insurers can lower monthly premiums for all planholders, she said.

The AIDS Foundation also sent letters to Health Alliance, which operates downstate, and to UnitedHealthcare.

Health Alliance places all single-pill regimens, along with a drug commonly combined with others to treat patients, on the fifth tier in a six-tier system, resulting in “mostly unaffordable” drug coverage for people with HIV, the foundation wrote.

Health Alliance spokeswoman Laura Mabry noted that the insurer places several of its HIV drugs in low-cost tiers. “Our goal continues to be providing choices that meet consumers’ needs, including their prescription drug needs,” she said in an emailed statement.

UnitedHealthcare classifies most of the drugs used in the HIV treatments as tier two but also marks them as specialty drugs. Daliah Mehdi, the AIDS Foundation’s chief clinical officer, said the insurer told her the specialty designation made those drugs more expensive than others in tier two. But a UnitedHealthcare spokesman told the Tribune the drugs were not more costly.

In Florida, the AIDS Institute and the National Health Law Program filed a complaint over the cost of four treatments with the Department of Health and Human Services’ civil rights office. The complaint is still under investigation, but Coventry, Humana and two other insurers voluntarily reduced prices after a Florida regulator questioned whether the insurers were violating state law.

Coventry capped the costs of the four treatments at $200 per month, while Humana limited patient payments to 10 percent of what the insurer pays for all HIV and AIDS drugs on its specialty tier.

On Friday, the federal Centers for Medicare & Medicaid Services issued a rule for 2016 that prohibits plan designs that place “most or all drugs that treat a specific condition on the highest cost tiers” and that charge more for single-tablet regimens than for treatments that require patients to take multiple pills.

About 37,000 Illinoisans had been diagnosed with HIV or AIDS as of December, with an average of 1,788 diagnosed each year from 2009 to 2013, according to the most recent Illinois Department of Public Health figures.

Information on how many HIV patients in Illinois have joined Affordable Care Act plans is not publicly available, but about 8,000 people who have received state help paying for their HIV or AIDS medication have signed up for a plan, joined Medicaid or are in the process of getting insurance, a health department spokeswoman said. About 9,300 people received help through the AIDS Drug Assistance Program last year, she said.

The state program now helps pay premiums and drug costs for the low-income recipients who have obtained insurance, along with those who are still uninsured, the spokeswoman said.

Patient advocates said lower drug prices would not only ensure access to treatment for HIV and AIDS patients but also help reduce the virus’ spread, as some of the treatments make transmission less likely.

Will Wilson, a 61-year-old Gurnee man who said he was diagnosed with AIDS 13 years ago, recently obtained insurance through his employer that covers nearly all the cost of his Atripla prescription.

After his diagnosis, Wilson said, he went broke paying for the 16 pills a day he took to keep the syndrome in check. Keeping his income low enough to qualify for state aid ultimately allowed him to afford treatment, he said. Now he works as an insurance navigator for a nonprofit organization, helping people understand their options.

Wilson said he thought the Affordable Care Act would bring a new measure of freedom for people with HIV and AIDS, but paying for treatment is still difficult for many. Even on health plans that pay relatively good rates for HIV and AIDS treatments, interpreting drug formularies and plan benefits to figure out a patient’s costs is extraordinarily complicated, he said.

“The system that was supposed to be easier for us is not easier,” Wilson said. “And once again we’re faced with (the question): We still have to fight for the drugs that keep us alive?”

On March 4, the justices will hear oral arguments in King v. Burwell, a case challenging the validity of tax subsidies helping millions of Americans buy health insurance if they don’t get it through an employer or the government. If the court rules against the Obama administration, those subsidies could be cut off for everyone in the three dozen states using healthcare.gov, the federal exchange website. A decision is expected by the end of June.

Here are five things you should know about the case and its potential consequences:

1: This case does NOT challenge the constitutionality of the health law.

The Supreme Court has already found the Affordable Care Act is constitutional. That was settled in 2012’s NFIB v. Sebelius.

At issue in this case is a line in the law stipulating that subsidies are available to those who sign up for coverage “through an exchange established by the state.” In issuing regulations to implement the subsidies in 2012, however, the IRS said that subsidies would also be available to those enrolling through the federal health insurance exchange. The agency noted Congress had never discussed limiting the subsidies to state-run exchanges and that making subsidies available to all “is consistent with the language, purpose and structure” of the law as a whole.

Last summer, the U.S. Court of Appeals for the Fourth Circuit in Richmond ruled that the regulations were a permissible interpretation of the law. While the three-judge panel agreed that the language in the law is “ambiguous,” they relied on so-called “Chevron deference,” a legal principle that takes its name from a 1984 Supreme Court ruling that held that courts must defer to a federal agency’s interpretation as long as that interpretation is not unreasonable.

Those challenging the law, however, insist that Congress intended to limit the subsidies to state exchanges. “As an inducement to state officials, the Act authorizes tax credits and subsidies for certain households that purchase health insurance through an Exchange, but restricts those entitlements to Exchanges created by states,” wrote Michael Cannon and Jonathan Adler, two of the fiercest critics of the IRS interpretation, in an article in the Health Matrix: Journal of Law-Medicine.

In any case, a ruling in favor of the challengers would affect only the subsidies available in the states using the federal exchange. Those in the 13 states operating their own exchanges would be unaffected. The rest of the health law, including its expansion of Medicaid and requirements for coverage of those with pre-existing conditions, would remain in effect.

2: If the court rules against the Obama administration, millions of people could be forced to give up their insurance.

A study by the Urban Institute found that if subsidies in the federal health exchange are disallowed, 9.3 million people could lose $28.8 billion of federal help paying for their insurance in just the first year. Since many of those people would not be able to afford insurance without government help, the number of uninsured could rise by 8.2 million people.

A separate study from the Urban Institute looked at those in danger of losing their coverage and found that most are low and moderate-income white, working adults who live in the South.

3: A ruling against the Obama administration could have other effects, too.

Experts say disallowing the subsidies in the federal exchange states could destabilize the entire individual insurance market, not just the exchanges in those states. Anticipating that only those most likely to need medical services will hold onto their plans, insurers would likely increase premiums for everyone in the state who buys their own insurance, no matter where they buy it from.

“If subsidies [in the federal exchange] are eliminated, premiums would increase by about 47 percent,” said Christine Eibner of the RAND Corporation, who co-authored a study projecting a 70 percent drop in enrollment.

Eliminating tax subsidies for individuals would also impact the law’s requirement that most larger employers provide health insurance. That’s because the penalty for not providing coverage only kicks in if a worker goes to the state health exchange and receives a subsidy. If there are no subsidies, there are also no employer penalties.

4: Consumers could lose subsidies almost immediately.

Supreme Court decisions generally take effect 25 days after they are issued. That could mean that subsidies would stop flowing as soon as July or August, assuming a decision in late June. Insurers can’t drop people for non-payment of their premiums for 90 days, although they have to continue to pay claims only for the first 30.

Although the law’s requirement that individuals have health insurance would remain in effect, no one is required to purchase coverage if the lowest-priced plan in their area costs more than eight percent of their income. So without the subsidies, and with projected premium increases, many if not most people would become exempt.

5: Congress could make the entire issue go away by passing a one-page bill. But it won’t.

All Congress would have to do to restore the subsidies is pass a bill striking the line about subsidies being available through exchanges “established by the state.” But given how many Republicans oppose the law, leaders have already said they will not act to fix it. Republicans are still working to come up with a contingency plan should the ruling go against the subsidies. Even that will be difficult given their continuing ideological divides over health care.

States could solve the problem by setting up their own exchanges, but that is a lengthy and complicated process and in most cases requires the consent of state legislatures. And the Obama administration has no power to step in and fix things either, Health and Human Services Secretary Sylvia Burwell said in a letter to members of Congress.

]]>http://kaiserhealthnews.org/news/5-things-to-know-about-the-supreme-court-case-challenging-the-health-law/feed/0Supreme Court Meets In Closed Conference To Decide On Hearing Same-Sex Marriage Cases From Several Stateskhnjulierlogo nprSupreme Court Insurance Subsidies Decision Could Trigger Price Spikeshttp://kaiserhealthnews.org/news/supreme-court-insurance-subsidies-decision-could-trigger-price-spikes/
http://kaiserhealthnews.org/news/supreme-court-insurance-subsidies-decision-could-trigger-price-spikes/#commentsThu, 26 Feb 2015 10:00:17 +0000http://kaiserhealthnews.org/?p=523726]]>Making health insurance available and affordable to millions of people who buy their own coverage was a key goal for backers of the federal health law known as Obamacare.

But if the Supreme Court strikes down the insurance subsidies of millions of Americans who rely on the federal insurance marketplace, it could leave many worse off than they were before the law took effect, say experts.

“The doomsday scenario could materialize and it does impact everyone” — those getting subsidies, as well as those paying the full cost of their plans on the individual market in states using the federal exchange, said Christopher Condeluci, an attorney who worked for Iowa Republican Sen. Charles Grassley on the Senate Finance Committee staff during the drafting of the law.

That’s because millions of consumers likely would drop their policies, which they could no longer afford without subsidies.

Most insurers could not drop plans without giving one-to-three months’ notice. But the companies remaining in the market would likely seek sharp increases in premiums for the following year, anticipating that the consumers most likely to hold onto their plans would be those needing medical care.

One Rand analysis projects that unsubsidized premiums could increase by almost half — an average annual increase of $1,600 for a 40-year-old — and that 70 percent of consumers would cancel their policies.

Those price increases, in turn, would drive more people to drop coverage, spurring further price hikes and potentially leading to what insurance experts call “a market death spiral.”

“It’s not the subsidy market that will fall apart, it’s the whole market” for everyone who doesn’t get job-based insurance coverage, said Robert Laszewski, a consultant for the insurance industry who is no fan of the health law. “There will be millions of Republicans who are not subsidy-eligible who are also going to get screwed.”

Legal Arguments

At issue in King v. Burwell — slated to be argued before the Supreme Court March 4 — is the basis of subsidies that go to millions of low- and moderate-income Americans in the approximately three dozen states that rely on the federal marketplace. More than 85 percent of the 8.6 million people who purchased plans in those states qualified for subsidies, administration officials say.

The law’s challengers point to four words in the Affordable Care Act that say subsidies shall be distributed through marketplaces “established by the state.” They argue that that wording bars the government from subsidizing insurance purchased through a federally administered exchange.

Supporters of the law argue that Congress intended the subsidies be available through both federally run and state-run markets, which they say is clear in reading the overall bill.

The ruling would have no effect on the subsidies provided to residents through state-run markets, such as those in California, New York and Washington.

The Obama administration has declined to discuss contingency plans, expressing confidence that it will prevail with the justices. “Congress would not pass a law that 87 percent of folks would not get subsidies, but people in say, New York, would,” Health and Human Services Secretary Sylvia Mathews Burwell said Wednesday.

Experts say Congress could also apply “fixes,” such as voting to allow subsidies to continue through the rest of the year.

But whether a Republican-controlled Congress that has pledged itself to the law’s repeal would agree to that is uncertain.

Aetna spokeswoman Cynthia Michener said the insurer is talking with lawmakers from both parties “about how to make a grand bargain should the Supreme Court decide against federal exchange subsidies.” A decision to strike the subsidies would likely “spur bipartisan action to resolve the issue promptly,” she added.

At the state level, officials could decide to establish state-run marketplaces, but they would have to move fast before the start of open enrollment for 2016, tentatively set to begin Nov. 1. And lawmakers in many GOP-led states are likely to resist such steps, citing opposition to the law.

Governors in at least five of the states — Louisiana, Mississippi, Nebraska, South Carolina and Wisconsin — told Reuters they would not create their own exchanges if the court invalidated subsidies.

In another four — Georgia, Missouri, Montana and Tennessee — politics could make it very difficult to set up a state program, Reuters reported.

Florida and Texas, where there is strong opposition to the health law, but also large numbers of residents benefitting from subsidized coverage, officials would face even tougher decisions. “Florida has the highest number of enrollees in the federal marketplace and guess who is running for president? The former governor of Florida,” said Condeluci.

That might make Florida lawmakers more agreeable to a solution that would keep subsidies flowing, he said, noting that “Republicans are going to be blamed for the subsidies ceasing.”

‘Nuclear Option’?

Insurers that sell plans in the federal exchange states would find themselves in a drastically changed market.

Joel Ario, a managing director at consultancy Manatt Health Solutions, said insurers are already working on rates for 2016, which are scheduled for submission by April — two months before the court is expected to rule.

As for the states, Ario estimated that perhaps one third would set up their own markets fairly quickly. If states move at the same rate as they have to expand Medicaid, it could take several years before two-thirds of states have their own markets he said.

Even if insurers wanted to drop coverage immediately in the event the high court struck the subsidies, most could not do so legally. State laws require anywhere from 30 days to 90 days’ notice for an insurer to exit a market. And, if they withdraw, they have to pull all their plans, not just those offered through the federal exchange.

Regulations keep insurers from coming back into the market for years, however, creating a disincentive to bail out, said Laszewski, whose clients include major insurers.

Many insurers don’t yet have contingency plans, he said, partly because it’s so hard to tell what may happen or what alternatives might be available.

“This is the nuclear option and there really isn’t a contingency plan for nuclear destruction,” Laszewski said.

Others don’t see a ruling against the administration in such dark terms.

“The Supreme Court generally doesn’t go out of its way to wreck the economy or the health system,” said Stuart Butler, a conservative scholar and senior fellow at the Brookings Institution.

He believes the court is likely to offer some temporary remedy, such as a grace period when the subsidies could continue to flow.

“The idea that there will be some cataclysm the day after is extremely unlikely,” Butler said. “We’ll see a number of states moving toward essentially setting up a state exchange. We could still see Texas and a few others saying no. But if two-thirds of states find a way to accommodate it, I don’t see that a critical mass for the collapse of the Affordable Care Act is there.”

]]>http://kaiserhealthnews.org/news/supreme-court-insurance-subsidies-decision-could-trigger-price-spikes/feed/0health law ruling 570khnjulieahealth law ruling 570Survey: With Health Law’s Help, Uninsured Rate Drops To Lowest Level In 7 Yearshttp://kaiserhealthnews.org/morning-breakout/survey-with-health-laws-help-uninsured-rate-drops-to-lowest-level-in-7-years/
http://kaiserhealthnews.org/morning-breakout/survey-with-health-laws-help-uninsured-rate-drops-to-lowest-level-in-7-years/#commentsTue, 24 Feb 2015 14:42:17 +0000http://kaiserhealthnews.org/?post_type=daily-breakout&p=523623]]>]]>http://kaiserhealthnews.org/morning-breakout/survey-with-health-laws-help-uninsured-rate-drops-to-lowest-level-in-7-years/feed/0khnsstapletonTax Time Reprieve For Obamacare Procrastinatorshttp://kaiserhealthnews.org/news/tax-time-reprieve-for-obamacare-procrastinators/
http://kaiserhealthnews.org/news/tax-time-reprieve-for-obamacare-procrastinators/#commentsFri, 20 Feb 2015 15:50:06 +0000http://kaiserhealthnews.org/?p=523062]]>The Obama administration said Friday it will allow a special health law enrollment period from March 15 to April 30 for consumers who realize while filling out their taxes that they owe a fee for not signing up for coverage last year.

The special enrollment period applies to people in the 37 states covered by the federal marketplace, though some state-run exchanges are also expected to follow suit.

People will have to attest that they first became aware of the tax penalty for lack of coverage when they filled out their taxes. They will still have to pay the fine, which for last year was $95 or 1 percent of their income, whichever was greater. This year, the penalty for not having insurance coverage is $325 per person or 2 percent of household income, whichever is greater. By signing up during the special enrollment period for 2015 they can avoid paying most of the tax penalty for this year.

The Affordable Care Act requires most Americans to have health insurance or pay a financial penalty. But some people may not realize they face a penalty for not having coverage until they file their tax returns ahead of the April 15 tax deadline.

The administration also said Friday it sent out the wrong information to 800,000 people to help them calculate whether they received too much of a subsidy for health coverage last year or too little. Those affected are being notified today by email or telephone – and are being asked to wait to file their taxes until after new 1095-A forms are sent in early March.

For the 5 percent of those affected who have already filed returns for 2014, more instructions are to come from the Treasury Department, officials said. The 800,000 represents about 20 percent of the total number of people who were sent 1095-A tax forms. Officials declined to say how the mistake occurred.

The administration would not estimate how many people it expects to take advantage of the new enrollment period. Millions of Americans who did not enroll in a plan are exempt from the requirement to buy coverage because their income is too little or they qualify for other exemptions. Officials said this special enrollment would be just for this year to account for people who did not hear or heed messages about the individual insurance mandate that was included in the health law approved by Congress in 2010.

So far, 11.4 million Americans have enrolled in private health insurance through Obamacare during the open enrollment period that ended on Sunday.

Separately, administration officials have said they will allow people who had trouble completing their enrollment by Feb. 15 to finish by Sunday Feb. 22. Officials estimated it would help fewer than 150,000 people.

Julie Appleby contributed to this story.

]]>http://kaiserhealthnews.org/news/tax-time-reprieve-for-obamacare-procrastinators/feed/0- Plenty of Time -khnphilipg- Plenty of Time -States Add Dental Coverage For Adults On Medicaid But Struggle to Meet Demandhttp://kaiserhealthnews.org/news/states-add-dental-coverage-for-adults-on-medicaid-but-struggle-to-meet-demand/
http://kaiserhealthnews.org/news/states-add-dental-coverage-for-adults-on-medicaid-but-struggle-to-meet-demand/#commentsWed, 18 Feb 2015 10:00:30 +0000http://kaiserhealthnews.org/?p=522195]]>FORT COLLINS, Colo. — When Pavel Poliakov’s small clothing shop in this picturesque college town closed last year, he felt lucky to be able to sign up for Medicaid just as Colorado expanded the program under President Barack Obama’s health law.

But when Poliakov developed such a severe toothache that he couldn’t eat on one side of his mouth, he was unable to find a dentist — even though Colorado had just extended dental benefits to adults on Medicaid. Eventually, he turned to a county taxpayer-supported clinic that holds a monthly lottery for new patients.

After snagging an appointment through a monthly lottery, Pavel Poliakov waits to see a dentist at the Health District of Northern Larimer County clinic in Fort Collins, Colo. (Photo: Phil Galewitz/Kaiser Health News)

Colorado was one of five states last year to begin offering routine dental coverage to millions of low-income adults in Medicaid — an unprecedented expansion. But like Poliakov, many have had trouble finding dentists willing to treat them because of Medicaid’s low reimbursements, according to providers, advocates and patients.

The upshot is that many Medicaid enrollees continue to live with the pain and discomfort of tooth decay and gum disease, which can exacerbate other health problems, such as heart disease, diabetes and rheumatoid arthritis. Eventually, some go to costly emergency rooms, which can do little but provide short-term pain relief.

“Translating Medicaid coverage into care is a significant problem,” said David Jordan, who directs the dental access project at Community Catalyst, a national consumer advocacy group based in Boston.

“The number of adults on Medicaid who are able to see a dentist is woefully short of where it needs to be.”

Many dentists are reluctant to participate in the government program for low-income Americans because it typically pays as little as half of what they get from patients with private insurance. For example, Medicaid in Colorado pays $87 for a filling on a back tooth and $435 for a crown, compared to the $150 and $800 that private patients typically pay.

While federal law requires states to provide dental coverage to children in Medicaid, adult dental coverage is optional. To save money, almost half the states either don’t provide any dental coverage for adults or cover only emergencies.

In addition to Colorado, California, Illinois and Washington added or restored adult dental benefits last year as they expanded Medicaid eligibility under the health law to those making up to 138 percent of the federal poverty level. The federal government pays the full cost of expansion through 2016, and then no less than 90 percent. The fifth state, South Carolina did not expand Medicaid eligibility, but added adult dental services to improve benefits.

Yet advocates in all five states say providers are struggling to keep up with demand.

“Getting oral health care is difficult, if not impossible, for many of Colorado’s Medicaid clients,” said a report released this month by the nonpartisan Colorado Health Institute, a health policy research organization. The study found that in the past year, the number of Coloradans eligible for Medicaid dental coverage, including children, tripled to nearly 1 million, while the number of dentists who say they treat Medicaid patients increased by only 17 percent — to 877 practitioners.

Safety net providers in Colorado, such as federally funded community health centers, have tried to fill the gap, but in many places appointments for new patients are gone within hours of becoming available. Eight Colorado counties lack any dentists and seven more don’t have a private dentist who accepts Medicaid or a safety net clinic offering dental services, the study found.

Pavel Poliakov gets a cavity filled by dentist Rob Gartland at a Fort Collins, Colo. clinic run by the Health District of Northern Larimer County. (Photo: Phil Galewitz/Kaiser Health News)

Colorado Medicaid officials say they have enough dentists in most places. “We’ve not had calls from legislators or stakeholders that we flat out can’t get people into dental services,” said Bill Heller, director of the state’s Medicaid dental program.

Still, the state last summer proposed paying dentists a $1,000 bonus for taking five new Medicaid clients and seeing them at least twice a year. But the Obama administration has yet to approve federal incentive money

With little political support to increase reimbursements to dentists, advocates have looked at other ways to boost care. The Colorado Dental Association has urged members to take new Medicaid dental patients to alleviate waits, but it’s unclear how many have done so.

Seeking other alternatives, Alaska and Minnesota have enacted regulations that allow dental therapists with two years of training to perform basic services, such as filling cavities, if they work under a dentist’s supervision. The therapists in those states are much more willing to see Medicaid patients.

But efforts to expand their use in other states have been opposed by the American Dental Association, which raises questions about patient safety. Dental therapist legislation is pending in Washington and South Carolina, along with several other states.

Meanwhile, patients with Medicaid continue to struggle to get care.

Officials at Promise Healthcare, a community health center in Champaign, Ill., say demand for dental services is so great they frequently turn clients away. Last month, more than 150 people called for one of 12 new patient appointments, said Executive Director Nancy Greenwalt. “Patients are desperate.”

Christina Peters, of the Washington Children’s Health Alliance, said only about 15 percent of adult Medicaid enrollees in that state received dental care last year after the benefit began.

In Hartsville, S.C., CareSouth , a community health center, has one dentist who’s seen 60 new dental patients in the past month— but more than 400 have sought care.

Alfredo Rodriguez, 51, a Longmont, Colo. landscaper, visited a dentist at the Salud Family Health Center in February with several loose and broken front teeth that made it hard to eat. “I’m so thankful to be here,” he said while waiting to get three teeth pulled and to be fitted for a partial denture.

The North Larimer County Health District dental clinic gets between 150 and 300 people entering its lottery each month, hoping to qualify for 50 or 60 slots. Over half the clinic’s 5,000 patients are on Medicaid.

Rob Gartland, a clinic dentist, says the value of Medicaid is that patients can afford more expensive procedures, such as crowns and root canals, rather than just extractions.

In Fort Collins at least, Medicaid patients will soon get more help when Salud’s clinic here adds a dentist later this winter.

Sitting in the center’s waiting area recently, Tiffany Rickman, 23, said she would definitely use the service. She says she feels pain every time she eats, but has been unable to get care. “I would really like to get into a dentist and have a place where I can be a regular patient,” she said.

]]>http://kaiserhealthnews.org/news/states-add-dental-coverage-for-adults-on-medicaid-but-struggle-to-meet-demand/feed/0khn_philg_dental1khnphilipgAfter snagging an appointment through a monthly lottery, Pavel Poliakov waits to see a dentist at the Health District of Northern Larimer County clinic in Fort Collins, Colo. (Photo: Phil Galewitz/Kaiser Health News)Pavel Poliakov gets a cavity filled by dentist Rob Gartland at a Fort Collins, Colo. clinic run by the Health District of Northern Larimer County. (Photo: Phil Galewitz/Kaiser Health News)Pregnant And Uninsured? Don’t Count On Obamacarehttp://kaiserhealthnews.org/news/advocates-want-obamacare-available-to-pregnant-women-any-time/
http://kaiserhealthnews.org/news/advocates-want-obamacare-available-to-pregnant-women-any-time/#commentsWed, 18 Feb 2015 05:01:30 +0000http://kaiserhealthnews.org/?p=522215]]>The Obama administration often touts the health benefits women have gained under the Affordable Care Act, including the option to sign up for coverage outside of open enrollment periods if they’re “having a baby.”

But advocates complain the special insurance enrollment period begins only after a birth. As a result, uninsured women who learn they are pregnant outside of the regular three-month open enrollment period, which this year ended Sunday, can get stuck paying thousands of dollars for prenatal care and a delivery — or worse, going without care.

The advocacy groups, including the March of Dimes, Planned Parenthood and Young Invincibles, are asking the administration to allow women to sign up whenever they become pregnant – a change opposed by the insurance industry. They say they’ve sought the change unsuccessfully for several years.

Speaking to reporters Wednesday, Health and Human Services Secretary Sylvia Burwell said the government does not list pregnancy among the “qualifying life events” that entitle people to special enrollment because “we have based it on how insurance companies made the determinations when they have periods for open enrollment.” She said the agency would consider arguments for making a change.

Cynthia Pellegrini, senior vice president of March of Dimes, notes that about half of pregnancies are unintended. And women often can’t predict when they will have a challenging pregnancy requiring more services.

The advocates have applauded the health law for including maternity coverage among the list of “essential benefits.” But they say that allowing women to get covered as soon as they’re pregnant would give them and their unborn children greater protection. It would also allow those with high-risk pregnancies to change plans to get more comprehensive coverage that might include access to certain hospitals and doctors.

The insurance industry contends that allowing reproductive-age women to enroll any time they become pregnant would give women an incentive to wait to buy coverage.

“If you only create incentives for people to enroll when they have a health need, it poses a tremendous risk to the risk pool and affordability for everyone else,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, the industry’s trade group. She said insurers would have more difficulty setting their prices because it would be harder to predict who would buy coverage.

Before the Affordable Care Act, individual insurance policies rarely included maternity coverage — and women could not buy policies after they became pregnant. Today, they can buy such coverage during open enrollment.

The Obama administration allows people to enroll outside of the regular enrollment period in several circumstances, including after adopting or having a child, losing other coverage, moving out of a plan’s service area or getting married. The list of so-called “qualifying events” is similar to the circumstances that allow people with employer-sponsored insurance to change their coverage outside of open enrollment. The administration last week said it was considering adding a special enrollment period for people who discover they owe a tax penalty due to lack of coverage.

“If you have to spend $10,000 to $20,000 out of pocket on maternity care, it certainly puts women in a difficult position and insurance coverage [after a child’s birth] would be coming too late for them,” said Christina Postolowski, health policy manager for Young Invincibles, the nonprofit which has worked with the administration to boost enrollment.

The group is releasing a report Wednesday that looks at the economic and health consequences of not making pregnancy “a qualifying event” to sign up for coverage any time.

Without access to a health plan, women may be more likely to forgo prenatal care because they can’t afford it, which can put them at higher risk for conditions than can affect their own health as well as that of their child, such as pregnancy-related diabetes and high blood pressure, the report said.